Copay Accumulator Adjustment Policies Impede Treatment Access for Patients with Rheumatoid Arthritis

Rheumatology Practice Management December 2018 Vol 6 No 6 - Advocacy News
Madelaine Feldman, MD
Coalition of State Rheumatology Organizations
The Rheumatology Group
New Orleans, LA

Patients who rely on prescription medications, including those with chronic diseases such as rheumatoid arthritis (RA), are facing a new barrier to treatment access. Copay accumulator adjustment programs (CAAPs) are the latest cost-shifting tactic used by insurers and pharmacy benefit managers (PBMs) to increase out-of-pocket costs for patients by thousands of dollars a year. These programs threaten a physician’s ability to treat his or her patients with chronic diseases, placing many life-sustaining medications out of reach and forcing patients to abandon their treatment regimens altogether.

Worded in technical or misleading language, CAAPs no longer count a patient’s manufacturer copay assistance toward his or her annual deductible or out-of-pocket maximum. This means that once a patient’s manufacturer copay assistance has been spent, the patient is responsible for the full price of the treatment until the deductible or out-of-pocket maximum is reached. Under this construct, insurance companies are ultimately able to collect double the patient’s annual deductible.

Businesses are enticed to include CAAPs in their company insurance policies with the promise of lower premiums. However, employers may not realize the effect that these programs will have on their employees, particularly individuals with chronic diseases and high-deductible plans who are the most vulnerable to negative financial consequences. Unfortunately, employer-sponsored plans are including CAAPs in their benefits package with greater frequency. In a recent survey by the National Business Group on Health, more than half of employers with >5000 employees said that they are considering incorporating a CAAP in 2019 or 2020.1 However, according to a recent AIMED Alliance publication, employers considering adding these programs may be at increased risk for liability and can potentially be in violation of a number of federal laws, such as the Affordable Care Act and the Federal Trade Commission Act, as well as Employee Retirement Income Security Act regulations.2

CAAPs only compound the issue of high healthcare costs for patients. According to the 2018 Kaiser Family Foundation Employer Health Benefits Survey, average patient deductibles have increased 212% over the past decade.3 In addition, many patients are seeing more instances of coinsurance, utilization management, and formulary tiering.

Numerous Americans, especially those living with chronic diseases, are not able to afford a steep increase in their out-of-pocket costs for medications. A recent IQVIA™ study found that as cost-sharing increases, especially greater than $125 for the cost of treatment, patients are much more likely to abandon their medications at the pharmacy counter.4 Accumulator adjustment policies, which were quietly slipped into the back pages of patients’ healthcare plans without their knowledge, limit their access to life-saving drugs.

Insurers and PBMs have argued that manufacturer assistance or copay coupons incentivize patients to use high-priced medications instead of generic alternatives. However, another recent report published by IQVIA™, which analyzed claims data from 2013 to 2017, found that the use of copay coupons for brand-name drugs that have at least 1 generic equivalent accounts for only 0.4% of the total commercial market volume.5 Many patients with RA and other chronic diseases use copay coupons so they can afford their medications, for which there are no generic or lower cost alternatives. Our patients rely on manufacturer assistance to live stronger, healthier lives, but copay accumulator adjustment programs threaten their ability to thrive.

CAAPs work against the goal of lowering costs in the system, placing an additional burden on patients and exacerbating their lack of access to quality healthcare. Patients with chronic and rare diseases, as well as those who rely on medications without a generic equivalent, must now hit their steep deductibles and cover expensive copayments. Limiting medication access for patients with chronic diseases can result in treatment abandonment, disease progression, and poorer overall health, which increases the need for expensive care and medical interventions. Therefore, these programs not only hurt patients today, but over time, they raise costs throughout the entire healthcare system.

We know that it is essential for chronically ill patients to remain on their treatment plans and have sustainable access to medications. Physicians, however, are not always on the front lines of troubleshooting issues at the pharmacy counter, which is why our front desk colleagues and office managers need to be aware of CAAPs so that they can offer guidance to patients. This guidance includes instructing patients to engage their employers and human resources departments on the issue at hand and encouraging patients to contact their state’s insurance commissioner to let him or her know the harm of these policies.

CAAPs disproportionately affect patients with RA and other chronic diseases. These new policies impede our ability to properly care for patients, who are now becoming the victims of discriminatory benefit designs. Insurance companies and PBMs need to understand the impact of these programs on our patients and immediately take action to end their implementation.


  1. NPR website. Why Some Patients Getting Drugmakers' Help Are Paying More. sections/health-shots/2018/05/30/615156632/why-some-patients-getting-drugmakers-help-are-paying-more. May 30, 2018 Accessed November 18, 2018.
  2. Employers Beware: Understanding the Costs and Liability Risks of Health Insurance Copay Accumulator Programs. November 2018. Accessed November 18, 2018.
  3. Kaiser Foundation. 2018 employer health benefits survey. October 3, 2018. Accessed November 5, 2018.
  4. Devane K, Harris K, Kelly K. Patient affordability part two: implications for patient behavior & therapy consumption. October 2018. Accessed November 5, 2018.
  5. IQVIA. An evaluation of co-pay card utilization in brands after generic competitor launch. January 2, 2018. Accessed November 5, 2018.
Related Items
Charting a New Course in Step-Therapy Legislation: Be a Vocal Advocate
Mary Jo Wideman, RN, BSN
Rheumatology Practice Management December 2018 Vol 6 No 6 published on January 7, 2019 in Advocacy News
Your Independent Voice Is Important
Shari Wilson
Rheumatology Practice Management October 2018 Vol 6 No 5 published on October 25, 2018 in Advocacy News
How to Organize a Walk to Cure Arthritis
Andre C. Smith, CMPM, CPB, CRHC
Rheumatology Practice Management August 2018 Vol 6 No 4 published on September 5, 2018 in Advocacy News
New Hampshire Enforcement of USP 797: An Update and Next Steps
Brian Nyquist, MPH
Rheumatology Practice Management June 2018 Vol 6 No 3 published on June 20, 2018 in Advocacy News
ATAP Continues Its Efforts to Increase Patient Access to Affordable Therapies
Judith Gorsuch, JD, Ethel D. Owen
Rheumatology Practice Management April 2018 Vol 6 No 2 published on April 16, 2018 in Advocacy News
New Hampshire’s Enforcement of USP 797 Pharmacy Standards in the Physician Office
Brian Nyquist, MPH
Rheumatology Practice Management February 2018 Vol 6 No 1 published on February 16, 2018 in Advocacy News
Last modified: January 7, 2019
  • American Health and Drug Benefits
  • Lynx CME
  • Value Based Care in Rheumatology
  • Oncology Practice Management
  • Urology Practice Management